PULMONARY COMPLICATIONS OF MECHANICAL VENTILATION

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Although mechanical ventilation of critically ill patients may be life-saving, associated complications occur commonly. In a prospective study by Zwillich et al,128 for example, a total of 400 complications of mechanical ventilation occurred in 354 consecutive patients. The spectrum of complications of intubation and mechanical ventilation is broad and includes injury to the lung parenchyma (e.g., volutrauma and acute lung injury), adverse hemodynamic consequences of positive-pressure ventilation, injury to the airways from intubation, and predisposition to infection (e.g., aspiration pneumonia, (Table 1). Recent publications, including an earlier review in this series, have addressed the broad range of such complications.55

The current review focuses on the physiology and adverse effects of positive intrathoracic pressure (PITP) and two selected pulmonary complications of mechanical ventilation: (1) volutrauma and acute lung injury and (2) airway complications of intubation and mechanical ventilation. With regard to positive intrathoracic pressure, the authors specifically review (1) the physiologic effects of PITP and positive end-expiratory pressure (PEEP) and (2) the types and mechanisms of adverse effects. Regarding volutrauma and acute lung injury, the authors address (1) the pathophysiology and clinical spectrum of volutrauma, (2) the frequency and risk factors for volutrauma, and (3) available strategies to lessen this risk. Finally, with reference to airway injury consequences of intubation, the article addresses: (1) the spectrum and frequency of airway complications, (2) evidence pertaining to risk factors, and (3) clinical recommendations regarding airway management. Comprehensive reviews of other systemic complications of mechanical ventilation (e.g., ventilator-associated pneumonia) are reviewed elsewhere in this issue.

Section snippets

PHYSIOLOGIC EFFECTS OF POSITIVE INTRATHORACIC PRESSURE

Hemodynamic and respiratory effects comprise the major physiologic effects of positive-pressure ventilation. The hemodynamic effects of positive intrathoracic pressure can be considered as systemic and pulmonary, both of which relate primarily to changes in lung volume and intrathoracic pressure (PITP).

PULMONARY VOLUTRAUMA

The result of pulmonary volutrauma is the presence of extra-alveolar air in abnormal locations in a patient receiving mechanical ventilation. Also in the spectrum of pulmonary volutrauma is ventilator-associated lung injury (VALI), which indicates parenchymal damage caused by mechanical ventilation.

Because volutrauma is a potentially lethal complication of mechanical ventilation, prompt recognition by the intensivist is important. The clinical manifestations of volutrauma are pulmonary

AIRWAY COMPLICATIONS OF MECHANICAL VENTILATION

Airway complications of mechanical ventilation relate to possible adverse effects of placing the endotracheal tube and to the sequelae of a tube's residence within the airway over time. Complications of indwelling tubes relate to effects of pressure against the tracheal mucosa, effects of traversing the vocal cords (in the case of endotracheal tubes), and effects of incising the anterior tracheal wall (in the case of a tracheostomy tube).

SUMMARY

Although life-saving, mechanical ventilation may be associated with many complications, including consequences of positive intrathoracic pressure, the many aspects of volutrauma, and adverse effects of intubation and tracheostomy. Optimal ventilatory care requires implementing mechanical ventilation with attention to minimizing adverse hemodynamic effects, averting volutrauma, and effecting freedom from mechanical ventilation as quickly as possible so as to minimize the risk of airway

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    Address reprint requests to James K. Stoller, MD, Vice Chairman, Department of Medicine, Head, Section of Respiration Therapy, Department of Pulmonary and Critical Care Medicine, A90, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44106

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